Full Name
Email
*
Phone
*
Date of birth
How would you describe your current lifestyle?
Sedentary
Moderately Active
Very Active
What is your current primary health goal?
Weight Management
Increasing Energy
Stress Reduction
Improving Fitness Levels
Other
What areas of your life do you feel the need for the most improvement?
Physical Health
Mental/Emotional Well-being
Work-Life Balance
Social Connections
What is your biggest challenge in achieving your health goals?
Time Management
Lack of Motivation
Unclear Guidance
Other
What does a successful wellness journey look life for you?
Feeling Energized Daily
Maintaining a Healthy Weight
Achieving Mental Clarity
Building Strong Relationships
Which of the following best describes your dietary habits?
Regularly Balanced
Occasionally Healthy
Needs Improvement
How would you rate your current level of stress and its impact on your life?
Low Impact
Moderate Impact
High Impact
Have you tried any wellness programs or strategies before?
Yes
No
Long Answer
What motivates you to pursue your health goals?
Personal Well-being
Family and Relationships
Career Aspirations
Future Plans
What is your preferred method for receiving support and information?
Online Courses
Group Workshops
How committed are you to making changes to improve your health?
Not Very Committed
Somewhat committed
Very committed